Prevention of sexually transmitted diseases and HIV in young military men: evaluation of a cognitive-behavioral skills-building intervention.

BACKGROUND: Military personnel deployed to foreign countries with high endemic rates of sexually transmitted diseases (STDs) are at risk. GOAL: To evaluate a cognitive-behavioral, skills-building intervention to prevent STDs in junior, enlisted, male US Marines deployed to the Western Pacific aboard ships with periodic liberty visits to foreign ports. STUDY DESIGN: This study, using a quasi-experimental design, assigned 584 men to a cardiopulmonary resuscitation training (n = 288) or a cognitive-behavioral intervention (n = 296). The intervention aimed to increase prevention knowledge, reduce high-risk psychosocial (motivation) factors, and build decision-making and communication skills to reduce risky sexual behaviors and alcohol consumption. RESULTS: Participation in the intervention was associated with increased knowledge regarding symptoms and treatment of STDs and HIV (P < 0.001), decreased alcohol use (P < 0.01), and sexual risk (P < 0.01) during liberty ports of call. CONCLUSION: A multiple-session, cognitive-behavioral, skills-building intervention can be successfully implemented for deployed military personnel.

Chlamydial infection and unplanned pregnancy in women with ready access to health care.

OBJECTIVE: To apply urine-based ligase chain reaction for Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) detection and standard urine-based pregnancy testing for Navy-enlisted women, and to compare the prevalence and epidemiologic correlates of these adverse reproductive outcomes. METHODS: Participants were surveyed and urine was collected for pregnancy testing using standard laboratory methods and detection of C. trachomatis and N. gonorrhoeae infection by ligase chain reaction. Self-administered surveys facilitated collection of demographics, sexual behavior, including contraceptive use, sexual partners, sexually transmitted disease, and pregnancy history. RESULTS: Among 299 of 314 participants, the prevalence of chlamydial infection was 4.7% and of pregnancy was 9.7%, with 48.3% of the pregnancies unplanned. Chlamydia trachomatis infection was univariately associated with having a new sex partner within the last 6 months, more sexual partners, single marital status, condom use, drinking until passing out or vomiting in the past 30 days (alcohol misuse), and current pregnancy. Unplanned pregnancy was univariately associated with young age, single marital status, inconsistent condom use, having a new sex partner within the last 6 months, and more recent sexual partners. Among the pregnant women, four (13.8%) were infected with C. trachomatis. CONCLUSION: The high rates of chlamydial infection and unplanned pregnancy found in this population of employed young women with ready access to health care and health education underscore the challenge of enhancing reproductive health via compliance with effective contraceptive and sexually transmitted disease prevention methods. This is a challenge that remains unmet.

Sexually transmitted diseases in a health maintenance organization teen clinic: associations of race, partner's age, and marijuana use.

OBJECTIVE: To determine the role of sociodemographic risk markers and behavioral risk factors associated with sexually transmitted diseases (STDs) in sexually experienced youth seeking care at an urban, general health maintenance organization teen clinic. DESIGN: Cross-sectional. PARTICIPANTS: A consecutive, racially and ethnically diverse sample of 285 sexually experienced youth who were preponderantly female (58.6%) and who were aged 16.7 years on average. METHODS: All participants completed a self-report questionnaire and were screened for Chlamydia trachomatis using the ligase chain reaction technique and for Neisseria gonorrhoeae and other STDs using conventional methods. RESULTS: Many of these youth were at high risk for STDs, having a self-reported history of sex with multiple partners (49.1%), sex with a new partner (42.5%), inconsistent use of condoms (71.9%), and frequent substance use (24.5% used marijuana 1-2 times per week or more). Sexually transmitted disease screening revealed that 11.6% of the participants had 1 or more STDs. A logistic regression analysis to determine the best model for predicting STDs indicated that youth who are African American (odds ratio, 3.34; 95% confidence interval, 1.52-7.35), had sexual partners who were 2 or more years older (odds ratio, 2.63, 95% confidence interval, 1.22-5.67), and used marijuana 1 to 2 times or more per week (odds ratio, 2.27; 95% confidence interval, 1.01-5.13) were more likely to have STDs at screening. CONCLUSIONS: A brief sociodemographic and behavioral risk assessment that includes these factors may be useful for clinicians in deciding when to screen for STDs in sexually active youth seeking care for reasons not related to reproductive health.

Cervical secretory immunoglobulin A in adolescent girls.

PURPOSE: To determine whether there are differences in levels of cervical secretory immunoglobulin A (sIgA) between adolescent girls in the secretory and proliferative phases of their menstrual cycle. METHODS: Sexually active adolescent girls (n = 117) at health maintenance organization (HMO) based adolescent medical clinic were recruited into the study. In addition to demographic and clinical data, cervical specimens were collected for sIgA measurement and gonorrhea culture, urine for chlamydia ligase chain reaction, and blood for progesterone levels. Subjects were classified as being in the proliferative phase or secretory phase of the menstrual cycle on the basis of their progesterone levels. RESULTS: The mean age of the subjects was 17.2 years old. There was no difference in the sIgA levels between those in the proliferative phase of their cycle (n = 45; mean sIgA level, 0.0055 mg/mL) and those in the secretory phase (n = 40; mean sIgA level, 0.0032 mg/mL) (p > .10). CONCLUSIONS: The secretory phase of the menstrual cycle does not appear to be associated with higher levels of sIgA in adolescent girls. These results suggest that adolescents with anovulatory cycles, i.e., those who lack a secretory phase, may not be at increased risk for genital tract infections such as chlamydia or gonorrhea.

Is the routine pelvic examination needed with the advent of urine-based screening for sexually transmitted diseases?

OBJECTIVE: To determine the most cost-effective method of screening for chlamydia and gonorrhea to prevent pelvic inflammatory disease (PID) in asymptomatic sexually active adolescent females. DESIGN: Cost-effectiveness decision analysis comparing pelvic examination with cervical screening (the current national standard) with a model of urine screening with ligase chain reaction testing for Chlamydia trachomatis and Neisseria gonorrhoeae. METHODS: Four strategies using decision analysis were compared for a potential cohort of 100000 asymptomatic sexually active young women: (1) pelvic examination screening in 100%; (2) urine screening in 100%; (3) actual predicted pelvic examination screening in 70%; and (4) actual predicted urine screening in 90%. Assumptions and costs were generated from published sources. MAIN OUTCOME MEASURES: Cases of PID prevented per year and cost to prevent a case of PID. RESULTS: A total of 1750 cases of PID would be predicted to occur per year with no screening. Strategy 1 would prevent the most cases of PID (1283) at a mean cost of $10230. Strategy 2 would prevent 1215 cases of PID at a mean cost of $5093. The marginal cost to prevent an additional case of PID by strategy 1 is $101454. Strategy 3 would prevent 898 cases of PID and 1093 cases of PID would be prevented with urine screening in strategy 4. CONCLUSION: Urine-based ligase chain reaction screening is the most cost-effective strategy to detect chlamydial and gonococcal genital infection in asymptomatic sexually active adolescent females and, owing to ease of implementation, the most likely to prevent the greatest number of cases of PID.

Predictors of risk for sexually transmitted diseases in ninth grade urban high school students.

This study examined risk factors associated with acquisition of sexually transmitted diseases (STDs) including HIV in adolescents, using the AIDS Risk Reduction Model. The study participants were 985 students who were 54% female, ethnically/racially diverse, had a mean age of 14.7 years, and were mostly 9th graders (74%). Logistic regression was used to predict sexual experience. Linear regression was used to predict risky sexual behaviors and condom use within the previous month. The results indicate that demographic factors are associated with being sexually experienced, but few demographics are associated with specific STD-related risk behaviors. STD and AIDS knowledge are not associated with any risk behaviors. Use of alcohol and drugs is associated significantly with being sexually experienced and sexual risk. The results also indicate that peer affiliation, perceptions of peer norms, perceptions of risk, perceptions of self-efficacy, and social support are associated with STD-related risk among sexually experienced youth.

Asymptomatic sexually transmitted disease prevalence in four military populations: application of DNA amplification assays for Chlamydia and gonorrhea screening.

The prevalence of asymptomatic chlamydial and gonococcal infections in male and female military populations was determined using urine-based ligase chain reaction DNA amplification assays (DAAs). Cross-sectional surveys in four military settings revealed an overall prevalence of asymptomatic chlamydial infection of 4.2% (56/1338). This included 3.4% (21/618) of Western Pacific shipboard US Marine Corps enlisted men; 5.2% (21/406) of male marines shore-based in Okinawa, Japan; 2.7% (5/183) of female enlisted US Navy subtender personnel in dry dock; and 6.9% (9/131) of shore-based female naval personnel in San Diego. No gonococcal infections were detected. All subjects were treated within 2 weeks of screening; none of them had progressed to symptomatic disease. General population-based screening for asymptomatic sexually transmitted diseases, and in particular chlamydial infection, can be successfully implemented using urine-based DAA tests. Benefits are maximized in a population in which compliance for follow-up therapy is high.

Evaluation of a knowledge- and cognitive-behavioral skills-building intervention to prevent STDs and HIV infection in high school students.

The purpose of this study was to evaluate the efficacy of a school-based knowledge- and cognitive-behavioral skills-building STD/HIV prevention intervention. Subjects were 513 ethnically and racially diverse students attending four urban public high schools. The sample was 59% female and had a mean age of 14.4 years. A quasi-experimental design was utilized to evaluate the intervention which consisted of three class sessions. Results of hierarchical regression analyses, controlling for baseline scores and demographic factors, indicate that this intervention was effective at increasing STD knowledge (p < .05), and skills related to prevention of risky sexual (p < .05) and drug use (p < .001) behavior. Although significant changes in risk behaviors were not detected, it is too soon to conclude that school-based education and skills building STD/HIV prevention interventions are ineffective at changing risk behaviors in adolescents. Implications for future study are addressed.

Adolescents' perceived risk for STDs and HIV infection.

PURPOSE: (1) To determine whether adolescents systematically underestimate their relative risk for STDs and HIV; and (2) to determine to what extent anxiety about STDs and HIV, past condom use, number of lifetime partners and STD/HIV-related beliefs predict perceived relative risk. METHODS: Two hundred and thirty-one sexually experienced, racially diverse, urban high school teenagers (mean age = 15.5 years; 53% male) were surveyed regarding their STD/HIV-related attitudes, beliefs, and behaviors. RESULTS: The subjects did not perceive themselves to be at lower risk compared to their perceptions of the risk of other people their age for STDs or HIV. Using hierarchical multiple linear regression analysis, perceptions of lower relative risk for STDs and for HIV were predicted by higher levels of anxiety (p < .001) but not by past condom use, number of lifetime partners or STD/HIV-related beliefs (p > .05). CONCLUSIONS: Adolescents' perceptions of risk appear to be related to anxiety about STDs and HIV and their behaviors may be related to peer influences and attitudes toward using condoms.

PIP: In 1991, 881 urban US high school students participated in a survey designed to determine their perceptions of risk for acquiring sexually transmitted diseases (STDs) and to test whether results of a previously reported clinic-based study on perceptions of risk are generalizable. Of the students, 278 had engaged in sexual intercourse, and 231 of these returned questionnaires with usable answers to each question. The analysis was based on this latter cohort. The mean age of this group was 15.5 years. 53% were male, 34% Black, 27% Hispanic, 14% Asian, 9% White, and 16% other. The perceived relative risks for STDs and HIV (dependent measures) were submitted to separate analysis using the 5-point Likert scales. Independent measures included demographic variables, STD and HIV anxiety, condom use, number of partners, and STD and HIV beliefs. It was found that 24% never used a condom and 43% always used condoms. The subjects showed no optimistic bias in their perceptions of the relative risk of STDs or HIV (they believed their risks to be the same as those of other people their age). The only variance found was that the White subjects believed themselves at less relative risk than the other subjects. These findings contrast those of the clinic-based study and suggest that perceptions of risk may vary among different cohorts. Higher levels of anxiety were also found to be associated with higher levels of perceived risk whereas other factors were not. A possible limitation of this study was that the group to which the study population was asked to compare itself was not clearly defined. However, this study indicates that sexually active adolescents are well aware of their STD and HIV risks and that their decision to engage in risky behavior may be due to factors other than a heightened sense of invulnerability (such as perception of social norms or alcohol use).

Detection of Chlamydia trachomatis in first catch urine samples from symptomatic and asymptomatic males.

BACKGROUND AND OBJECTIVES: Non-invasive tests are needed to detect Chlamydia trachomatis in the genital tract. For men, urine appears to be a useful specimen for chlamydial antigen or nucleic acid detection. GOAL OF THIS STUDY: To evaluate enzyme immunoassays (EIA) for chlamydial antigens in first catch urine (FCU) from symptomatic and asymptomatic men. STUDY DESIGN: We conducted five different studies; FCUs and urethral swabs were collected from 1,341 symptomatic and 816 asymptomatic males. Four EIAs (SureCell, Chlamydiazyme, MicroTrak and IDEIA) were tested on the FCU sediments. RESULTS: Prevalence of chlamydia by tissue culture isolation was 6% for asymptomatic and 14% for symptomatic men. With symptomatic males, the EIA sensitivities and specificities were: SureCell 85% and 97%, IDEIA 82% and 98%, MicroTrak 86% and 99%, and Chlamydiazyme 91% and 95%. For asymptomatic men, Chlamydiazyme sensitivity was 35% with frozen urine vs 77% with fresh urine. Overall, tissue culture sensitivity was about 90%. CONCLUSION: EIA results on FCU sediments are comparable to that of tissue culture isolation on urethral swabs. In many settings, FCU may be the specimen of choice for diagnosing chlamydial infections in men.

Relationship between drug use and sexual behaviors and the occurrence of sexually transmitted diseases among high-risk male youth.

BACKGROUND AND OBJECTIVES: Sexually active adolescents, especially those in detention, are at high risk for acquisition of sexually transmitted diseases (STDs), including HIV infection. Yet little information is available that describes their risk behaviors associated with STDs. The overall objective was to define the relationship between risk behaviors and STD acquisition among adolescents. GOALS OF THIS STUDY: The first goal was to characterize drug use and sexual behaviors that place a population of adolescent male detainees at STD/HIV risk. The second goal was to define possible interrelationships between drug use, especially alcohol use, and risky sexual behaviors with STD acquisition. STUDY DESIGN: The study group consisted of 414 adolescent male detainees 12 to 18 years of age who participated in an interview and a clinical assessment. Two hundred sixty-nine of the 414 subjects agreed to STD laboratory tests, including serologic testing for hepatitis B and syphilis, and urethral cultures to screen for chlamydial and gonorrheal urethritis. RESULTS: Results showed that 15% had current evidence of at least one STD, and 34% had a history or current evidence of at least one STD (STD occurrence). The subjects were frequently engaging in risky sexual and drug use behaviors. Two multivariate models described three factors that significantly place the male adolescent in detention at risk for STDs: multiple sexual partners, inconsistent condom use, and the quantity of alcohol consumed per week. CONCLUSION: Youth in detention place themselves at risk for STDs including HIV because of their risky sexual behavior and drug use. Addressing alcohol use and barriers to condom use appear to be essential components of any STD prevention program targeting this largely minority youth population.

Evaluation of urine-based screening strategies to detect Chlamydia trachomatis among sexually active asymptomatic young males.

OBJECTIVE: To evaluate the performances of diagnostic screening tests alone or in combination to detect asymptomatic chlamydial urethral infection in young males. DESIGN: Comparisons of the performance profiles of the following chlamydia screening strategies were done: urethral culture; identification of polymorphonucleocytes (PMNs) on spun first-void urine (FVU); urinary leukocyte esterase test (LET) on unspun FVU; chlamydial enzyme immunoassay (EIA) applied to FVU sediment; combining LET on unspun FVU followed by EIA with or without direct fluorescent antibody (DFA) confirmation on FVU sediment; and combining PMNs on spun FVU followed by EIA with or without DFA confirmation. SETTING: General clinics at a youth detention center, university-based teen clinic, college health service, and a military screening clinic. PATIENTS: A total of 618 males aged 12 to 35 years (mean, 17 years) were recruited as a convenience sample; site participation rates ranged from 50% to 80%. Eligible subjects were sexually active, denied symptoms of urethritis, and had taken no antibiotics in the prior 2 weeks. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values of each test strategy's ability to detect Chlamydia trachomatis infection, and cost to confirm each positive case. RESULTS: With a 7% prevalence of chlamydial infection, tissue culture had a sensitivity of only 61%. However, two strategies yielded significantly better performance profiles compared with the others: EIA confirmed by DFA test with a sensitivity of 84%, a specificity of 100%, and a cost to identify each positive case of $434; and PMNs followed by EIA confirmed by DFA test with a sensitivity of 78%, a specificity of 100%, and a cost to identify each positive case of $199. The LET followed by EIA-DFA had a similar performance profile to the PMN test strategies. CONCLUSIONS: A combination of a nonspecific screening of FVU for PMNs or LET followed by specific testing with EIA with DFA confirmation has superior clinical and cost-effective performance for detecting asymptomatic C trachomatis urethritis in young males compared with other strategies. However, an evaluation of the medical, fiscal, and psychological benefits and risks associated with a specific screening strategy for sexually transmitted diseases must be made before adopting a specific strategy for a particular population.

Implementing a school-based STD/HIV prevention intervention: collaboration between a university medical center and an urban school district.

To effectively implement a school-based STD/HIV prevention intervention program developed by a community-based agency, several issues must be addressed to build a collaborative partnership between the agency and the school district. Steps taken by the Division of Adolescent Medicine, University of California, San Francisco, in achieving partnership with a local urban school district are outlined. The process of recruiting school district administrators, health education liaisons, teachers, parents, and students is emphasized.